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ENCOUNTER EDIT CODE DESCRIPTIONS Last Upload 5/17/2021

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EDIT 001 - INCORRECT CLAIM STATUS CODE This edit is posted to any encounter claim if it has been assigned an invalid claim status code by the MMIS. This edit is for internal use and has no applicability to data provided by the HMO. EDIT 002 - BILLING PROVIDER NUMBER MISSING/INVALID This edit is posted to any encounter claim if the billing provider number is invalid (non-numeric or spaces) or contains the HMO Medicaid provider number (0155179, 0336971, 0398799, 5451302, 6228704, 6228607, 6700403, 6231004). EDIT 003 - PROCEDURE CODE/CAPITATION PROVIDER TYPE UNMATCHED This edit is posted to a capitation true-up encounter (procedure code TRUUP) if the capitation provider type is not 997, 998, or 999. This edit is posted to a capitation detail encounter (procedure code CAPDT) or a capitation summary encounter (procedure code SUMRY) if the capitation provider type is not 100, 200, 300, 400, 500, 600, 700, 800, 900, 910, 920, 930, 940, 950, 960, 970, 980, or 990. EDIT 004 - PRESCRIBING PROVIDER MISSING/INVALID This edit is posted to a pharmacy (claim type 12) encounter claim if the prescribing SSN or EIN is either invalid (non-numeric or spaces) or missing. EDIT 005 - ATTENDING PROVIDER MISSING/INVALID This edit is posted to a inpatient (claim type 01), outpatient (claim type 03), or home health (claim type 06), encounter claim if the attending SSN or EIN is either invalid (non-numeric or spaces) or missing. EDIT 006 - REFERRING/OPERATING/OTHER PROVIDER MISSING/INVALID This edit is posted as follows: 1. Professional, Dental and Inpatient Referring Provider This edit is posted to an encounter professional or Inpatient claim if the referring provider EIN/SSN was submitted (not zeroes or spaces), but is invalid (non-numeric). 2. Inpatient Operating Provider This edit is posted to an inpatient encounter claim if the operating provider EIN/SSN was submitted (not zeroes or spaces), but is invalid (non-numeric). 3. Outpatient Other Provider This edit is posted to an outpatient encounter claim if the Other Provider EIN/SSN was submitted (not zeroes or spaces), but is invalid (non-numeric). EDIT 009 - SERVICING PROVIDER NAME MISSING This edit is posted to any encounter claims if the name of the servicing provider is missing.


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EDIT 010 - SERVICING PROVIDER MISSING/INVALID This edit is posted differently depending on the HIPAA version of the encounter: 1. This edit is posted to any 4010A1 version encounter claim if the servicing provider SSN or EIN is

missing or invalid. The servicing provider EIN or SSN is required on all 4010A1 encounter claims submitted. 2. This edit is posted to any 5010 version encounter claim if both the servicing provider NPI and EIN or

SSN are missing. Either the Servicing Provider NPI or EIN or SSN is required on all 5010 encounter claims submitted. EDIT 011 - RECIPIENT NUMBER MISSING OR INVALID This edit is posted to an encounter claim if the Recipient ID (E-CURRENT-RECIP-ID-NUM) is not numeric or the Person Number of the Recipient ID (11th and 12th digits) is not 01 – 49. EDIT 013 - INVALID BIRTHDATE This edit is posted to any encounter claim if the birth date is invalid. In other words, the birth date is non-numeric, equal to zeros, or failed standard date editing routines. EDIT 014 - PCA SERVICE SUBMITTED AS OVERTIME This edit is set on CT04 Encounters with the following: 1. DOS is after 3/29/2020 AND 2. Service code/modifier is T1019/SE, T1019/SE/U1, S5125/SE/HQ or S5125/SE/U3 AND 3. TU modifier for overtime is present. EDIT 015 - STATEMENT THRU DATE < STATEMENT FROM DATE This edit is posted to an outpatient (claim type 03) or home health (claim type 06) encounter claim if the statement thru date is less than the statement from date. EDIT 016 - SERVICE FROM DATE MISSING/INVALID This edit is posted to any encounter claim if the service from date is either missing or invalid. In other words, the service from date is non-numeric, equal to zeros, or failed standard date editing routines. EDIT 017 - SERVICE THRU DATE MISSING/INVALID This edit is posted to any encounter claim if the service thru date is either missing or invalid. In other words, the service thru date is non-numeric, equal to zeros, or failed standard date editing routines. EDIT 018 - SERVICE THRU DATE < SERVICE FROM DATE This edit is posted to any encounter claim if the service thru date is less than the service from date.


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EDIT 019 - SERVICE PERIOD IS MORE THAN 3 YEARS OLD This edit is posted to any encounter claim if the service period is more than three years prior to the date of processing. EDIT 020 - SERVICE THRU DATE > DATE RECEIVED This edit is posted to any encounter claim if the service thru date is greater than the Julian date in the first five positions of the ICN. EDIT 021 - INVALID CLAIM FORMAT-NCPDP D.0 IS IN MANDATORY PERIOD This edit is applicable to Encounter pharmacy claims only. This edit will be applied on or after April 1, 2012, based on Claim Cycle Date. It will be applied to pharmacy claims submitted electronically that are not in NCPDP D.0 format. After March 31, 2011, the Version Number on the claim must contain 'D0' or the claim will receive this edit. EDIT 022 - CAPITATION SERVICE PERIOD INVALID This edit is posted to a capitation detail encounter (procedure code CAPDT) if the service period is prior to July, 2009. This edit is posted to a capitation true-up encounter (procedure code TRUUP) if the service period is prior to September, 2009. EDIT 023 - VOID MATCHED MULTIPLE ENCOUNTERS This edit is posted to a pharmacy (claim type 12) encounter void claim if more than one match is found on the PHARMENC file based on NPI, Date of Service, Prescription number and NDC. NOTE: Encounters for HMO denied claims submitted on or after June 1, 2013 bypass edits 023 and

024. Encounters for denied HMO claims are identified with edit 144. EDIT 024 - DUPLICATE PHARMACY/SERVICE DATE/PRESCRIPTION NUMBER This edit is applicable to pharmacy claims only: This edit is posted when an original claim is received where another paid claim is found in the Claims History file with the same Provider ID, Date of Service, Prescription Number and NDC. Action: Assign Different RX number. NOTE: Encounters for HMO denied claims submitted on or after June 1, 2013 bypass edits 023 and

024. Encounters for denied HMO claims are identified with edit 144. EDIT 025 - DISPENSED DATE INVALID This edit is posted to a vision (claim type 08) encounter claim if the dispense date is invalid. In other words, the vision dispense date is non-numeric, other than spaces, or failed standard date editing routines. EDIT 026 - CLAIM EXCEEDS TIMELY FILING LIMITS This edit is posted to any encounter claim if the service date (or as of 7/1/2009 Service Date Thru for inpatient encounters) is 365 days less than the Julian date in the first five positions of the ICN. NOTE: Effective 07/01/2009 when other payers are involved (TPL) the time limit is extended from 12 months to 18 months.


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EDIT 027 - NO MATCHING CLAIM FOR ENC VOID/ADJ ON PHARMACY VSAM FILE This edit is posted to any pharmacy void or adjustment encounter claim if no match is found on the Pharmacy VSAM file for NPI, Date of Service, RX number, and HMO ICN Number (from D.0 A7 segment). Claim types other than Pharmacy will continue to receive edit code 799. NOTE: Encounters for HMO denied claims submitted on or after June 1, 2013 bypass edits 023 and

024. Encounters for denied HMO claims are identified with edit 144.

Encounters for HMO denied claims submitted on or after June 24, 2013 bypass edit 027. EDIT 042 - TYPE OF BILL CODE MISSING/INVALID This edit posted to an inpatient (claim type 01), outpatient (claim type 03), or home health (claim type 06) encounter claim if the type of bill is either missing or not one of the following values:

Inpatient 111-115, 117, 118, 121-125, 127, 128, 181-185, 187, 188, 211-215, 217, 218, 281-285, 287, 288, 651-655, 657, 658, 661-665, 667, 668, 841-845, 847, 848

Outpatient 131-135, 137, 138, 141-145, 147, 148, 221-225, 227, 228, 231-235, 237, 238, 711-715,

717, 718, 721-725, 727, 728, 731-735, 737, 738, 741-745, 747, 748, 751-755, 757, 758, 761-765, 767, 768, 771-775, 777, 778, 791-795, 797, 798, 821-825, 827, 828, 831-835, 837, 838, 851-855, 857, 858

Home Health with date of service < 01/01/2014

321-325, 327, 328, 329, 331-335, 337, 338, 339, 341-345, 347, 348, 349, 811-815, 817, 818, 819

Home Health with date of service => 01/01/2014

321-325, 327, 328, 329, 341-345, 347, 348, 349, 811-815, 817, 818, 819 EDIT 043 - INVALID MISSING BIRTH WEIGHT The edit is posted to the claim if the admit date is equal to the date of birth that comes in on the claim (indicating a newborn), and A. The birth weight is equal to zeroes, or B. The birth weight is not numeric, or C. The birth weight is not in the range of 100-9000 (grams). EDIT 044 - ADMISSION TYPE MISSING/INVALID This edit is posted to an inpatient (claim type 01) or outpatient (claim type 03) encounter claim if the type of admission is either missing or not one of the following values:

1 - Emergency 2 - Urgent 3 - Elective 4 - Newborn 5 - Trauma Center 9 - Information Not Available


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EDIT 045 - PATIENT STATUS CODE MISSING/INVALID This edit is posted to an inpatient (claim type 01) encounter claim if the patient status is either missing or not one of the following values:

01 - Discharged Home/Self Care 02 - Discharged/Transferred Short Term Hospital 03 - Discharged/Transferred to SNF 04 - Discharged/Transferred to ICF 05 - Discharged/Transferred Another Institution Type 06 - Discharged/Transferred Home-Home Health Agency 07 - Left Against Medical Advice 08 - Discharged/Transferred to Home Under Care of a Home IV Provider 20 - Expired 30 - Still Patient 43 - Discharged/Transferred to a Federal Health Care Facility 50 - Hospice-Home 51 - Hospice-Medical Facility 61 - Discharged/Transferred to hospital-based Medicare approved Swing Bed 62 - Discharged/Transferred to an Inpatient Rehabilitation Facility (IRF) 63 - Discharged/Transferred to a Medicare Certified Long Term Care Hospital (LTCH) 64 - Discharged/Transferred to a Nursing Facility Certified by Medicaid but not Medicare 65 - Discharged/Transferred to a Psychiatric Hospital 66 - Discharged/Transferred to a Critical Access Hospital 70 - Discharged/Transferred to another type of healthcare facility not defined elsewhere NOTE: 01-08, 20, 30, 43, 50, 51, 61, 62, 63, 64, 65, 66, 70 are the current valid entries. However, 08 is not

valid on UB-04 inpatient claims/encounters.


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EDIT 046 - INVALID/MISSING OCCURRENCE SPAN CODE The program checks each occurrence of occurrence span data on the Claim Activity Record. This edit is posted if one of the conditions listed below is encountered: 1. The occurrence span from or thru date is greater than zeros and the occurrence span code within the

same occurrence of occurrence span data is equal to spaces. 2. The occurrence span code on the claim is not equal to spaces and is not equal to one of the following

values: 70 - Qualifying Stay Dates for SNF Use Only 71 - Prior Stay Dates 72 - First/Last Visit Dates 73 - Benefit Eligibility Period 74 - Non-Covered Level of Care/Leave of Absence Dates 75 - SNF Level of Care Dates 76 - Patient Liability Period 77 - Provider Liability Period 78 - SNF Prior Stay Dates 79 - Payer Code 80 - Prior Same-SNF Stay Dates for Payment Ban Purposes M0 - QIO/UR Approved Stay Dates M1 - Provider Liability - No Utilization M2 - Inpatient Respite Dates M3 - ICF Level of Care Dates M4 - Residential Level of Care Dates MR - Reserved for Disaster Related Occurrence Span Code EDIT 047 - INVALID/OCCURRENCE SPAN FROM OR THRU DATE The program checks each occurrence of occurrence span data (4 occurrences) on the Encounter Claim. This edit is posted to an Encounter Claim if: 1. The occurrence span code is not equal to spaces, and the occurrence span FROM date or the

occurrence span THRU date is numeric and greater than zero, but does not pass standard date editing, or

2. The occurrence span code is other than 70, 71, 72, 78, or 80 and any part of the occurrence date span

falls outside the service period (i.e. the occurrence span FROM or THRU date is either less than the service FROM date or greater than the service THRU date).

EDIT 048 - SURGICAL PROCEDURE CODE MISSING/INVALID This edit is posted to an inpatient (claim type 01) or outpatient (claim type 03) encounter claim if the surgical procedure code is either missing or invalid (equal to spaces). This field is required when a surgical date is specified.


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EDIT 049 - SURGICAL DATE MISSING/INVALID This edit is posted to an inpatient (claim type 01) or outpatient (claim type 03) encounter claim if the surgical date is missing or invalid. In other words, the surgical date is non-numeric, equal to zeros, or failed standard date editing routines. This field is required when a surgical procedure code is specified. EDIT 056 - REVENUE UNITS MISSING/INVALID This edit is posted to an inpatient (claim type 01) or home health (claim type 06) if the revenue code is greater than 001 and the revenue units are not greater then zero, or This edit is posted to an outpatient (claim type 03) encounter claim if the revenue code is 300-319 (lab), 450-459 (emergency), 510, 511, 519 (clinic), 634, 635, 821, 829, 831, 841, 851, or 859 (ERSD), and the revenue units are not greater than zero. EDIT 058 - REVENUE/CHARGE/CODE INVALID This edit is posted to an inpatient (claim type 01), outpatient (claim type 03), and home health (claim type 06) claims if a revenue code is present and the revenue charge is non-numeric or the revenue code is non-numeric or less than 001. EDIT 059 – MULTIPLE OCCURRING PROCEDURE WITH ARC 59 This edit is posted to a dental (claim type 11) encounter if an Adjustment Reason Code '59' was submitted on the 837 Dental transaction, marking the claim as one that the HMO paid their provider $0 because the service is a multiple occurring service that is paid only for the final service delivery.


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EDIT 060 - OCCURRENCE CODE MISSING/INVALID This edit is posted to an inpatient (claim type 01), outpatient (claim type 03), or home health (claim type 06) encounter claim if the occurrence date is greater than zeros and the occurrence code is spaces, or not one of the following values: 01 - Auto Accident 02 - Auto Accident - No Fault Insurance 03 - Accident/Tort Liability 04 - Accident/Employment Related 05 - Other Accident 06 - Crime Victim 09 - Start Of Infertility Treatment Cycle 10 - Last Menstrual Period 11 - Onset of Symptoms/Illness 12 - Date Of Onset For A Chronically Dependent Individual 16 - Date Of Last Therapy 17 - Date Outpatient Occupational Therapy Plan Established Or Last Reviewed 18 - Patient Date of Retirement 19 - Spouse Date of Retirement 20 - Guarantee of Payment Began 21 - UR/PSRO Notice Received 22 - Date Active Care Ended 24 - Date Insurance Denied 25 - Date Benefits Terminated/Primary Payer 26 - Date SNF Bed Available 31 - Date Patient Notified - Bill Accommodations 32 - Date Patient Notified - Bill Procedures 33 - First Day, First Month 12 Month ESRD Period 34 - Date Election Extended Care Facilities 35 - Date Treatment Started 36 - Date of Discharge - Transplant Procedure 37 - Date Of Inpatient Hospital Discharge For Non-Covered Transplant Patient 38 - Date Treatment Started For Home IV Therapy


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EDIT 060 - OCCURRENCE CODE MISSING/INVALID (cont'd) 39 - Date Discharged On A Continuous Course Of IV Therapy 42 - Date of Discharge 43 - Scheduled Date of Canceled Surgery 44 - Date Treatment Started Occupational Therapy 45 - Accident Hour 46 - Date Treatment Started For Cardiac Rehabilitation 47 - Date Cost Outlier Status Begins 50 - Assessment Date (Effective 1/1/11) 51 - KT/V Reading (Valid for CT 03) 52 - Medical Certification/Recertification Date (Effective 1/1/11) 54 - Physician Follow-Up Date (Effective 1/1/11) 55 - Date Of Death (Effective 10/1/12) 70 - SNF Billing 71 - Payer Code 74 - Non-Covered Level of Care 79 - Payer Code A1 - Birthdate - Insured A B1 - Birthdate - Insured B C1 - Birthdate - Insured C A2 - Effective Date - Insured A Policy B2 - Effective Date - Insured B Policy C2 - Effective Date - Insured C Policy A3 - Benefits Exhausted B3 - Benefits Exhausted C3 - Benefits Exhausted J3 - Charity Care Write-Off Date A4 - Split Bill Date For Outpatient and Home Health claims with a Service thru date that is on or after October 12, 2015, occurrence codes '70', '74' '79' are no longer valid. For inpatient claims with a Service thru date on or after October 12, 2015, Occurrence Codes '60' '61' '70', '74' '79' are no longer valid. EDIT 064 - SERVICE THRU DATE > STATEMENT THRU DATE This edit is posted to an outpatient (claim type 03) or home health (claim type 06) encounter claim if the service thru date is greater then the statement thru date.


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EDIT 068 - ADMISSION SOURCE MISSING/INVALID This edit is posted to an inpatient (claim type 01) encounter claim if the source of admission is either missing or not one of the following values: 1, 2, 4, 5, 6, 8, 9, D, E, or F. OR If the admission type is 4, this edit is posted if the source of admission is not one of the following values: 5 or 6. EDIT 069 - OCCURRENCE DATE MISSING/INVALID This edit is posted to an inpatient (claim type 01), outpatient (claim type 03), or home health (claim type 06) encounter claim if the occurrence date is invalid or missing. In other words, the occurrence date is non-numeric, equal to zeros, or failed standard date editing routines. EDIT 071 - STATEMENT COVERS FROM DATE MISSING/INVALID This edit is posted to an outpatient (claim type 03) or home health (claim type 06) encounter claim if the statement covers from date is invalid or missing. In other words, the statement covers from date is non-numeric, equal to zeros, or failed standard date editing routines. EDIT 072 - STATEMENT COVERS THRU DATE MISSING/INVALID This edit is posted to an outpatient (claim type 03) or home health (claim type 06) encounter claim if the statement covers thru date is invalid or missing. In other words, the statement covers thru date is non-numeric, equal to zeros, or failed standard date editing routines. EDIT 073 - SERVICE COVERS FROM DATE < STATEMENT FROM DATE This edit is posted to an outpatient (claim type 03) or home health (claim type 06) claim if the service from date is less than the statement covers from date. EDIT 074 - STATEMENT COVERS FROM DATE > SERVICE THRU DATE This edit is posted to an outpatient (claim type 03) or home health (claim type 06) claim if the statement covers thru date is greater than the service thru date.


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EDIT 081 - CLINIC CODE INVALID This edit is posted to an outpatient (claim type 03) encounter claim if the clinic code is not spaces and not one of the following values:

01 - Alcoholism 02 - Allergy 03 - Arthritis, Rheumatology 04 - Cardiac, Cardiovascular Pacemaker 05 - Chest, TB 06 - Dental 07 - Dermatology 08 - Diabetic, Endocrine 09 - Eye, Ent 10 - Family Planning 11 - Gynecology 12 - Hematology 13 - Medical Gastrointestinal Gastroenterology 14 - Neurology, Neurosurgery 15 - OB, Prenatal 16 - Orthopedic 17 - Pediatric 18 - Physical Therapy, Physical Medicine, Rehabilitation 19 - Podiatry 20 - Proctology 21 - Psychiatry, Mental Health 22 - Speech and Hearing, Speech Pathology 23 - Surgery, Plastic Surgery 24 - Tumor 25 - Urology 26 - Other 27 - EPSDT 28 - Partial Hospitalization

EDIT 083 - SURGICAL PROCEDURE CODE MISSING This edit is posted to inpatient (claim type 01) claim if the first occurrence of surgical procedure code is equal to spaces and the billed revenue code is one of the following: 099, 360, 361, 362, 367, 369, 370, 374, 379, 490, 499, 710, 719. EDIT 085 - DAYS/UNITS/VISITS MISSING/INVALID This edit is posted to any encounter claim(s) if the following is true: - the revenue units is non-numeric or zeros for outpatient (claim type 03) or home health (claim type 06)

encounter claims, or - the drug quantity is non-numeric or zeros for pharmacy (claim type 12) encounter claims, or - the service units is non-numeric or zeros for all other encounter claims. Note: For compound pharmacy encounter claims, this edit will post if any of the compound ingredient quantities is not greater than zero.


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EDIT 086 - ASSISTED LIVING SERVICE UNITS NOT EQUAL TO SERVICE DAYS This Edit gets posted if the following conditions are met 1. If the Encounter Claim is an Encounter professional claim (CT = 04) AND

2. Procedure code on the Encounter claim is T2031 (Assisted Living) AND

3. Service Units on the Encounter claim are either -

a) Greater than Service Days Span calculated as (SERVICE THROUGH DATE - SERVICE FROM DATE + 2) OR

b) Less than (SERVICE THROUGH DATE - SERVICE FROM DATE) EDIT 087 - SURGICAL PROVIDER MISSING/INVALID 1. Inpatient Operating Provider NPI

This edit is posted to an inpatient encounter claim if (1) surgery is indicated (either an ICD-9 surgical procedure code is present or an ICD-10 surgical procedure code and surgery indicator are present), and (2) the Operating Provider NPI is missing (less than or equal zeroes).

2. Outpatient Other Provider NPI

This edit is posted to an outpatient encounter claim if surgery is indicated, and the Other Provider NPI is missing(less than or equal zeroes).

EDIT 088 - DATE OF SURGERY < SERVICE/STATEMENT FROM DATE This edit is posted to an inpatient (claim type 01) or outpatient (claim type 03) claim if there is a valid surgical procedure code and surgery date, and the surgery date is less than a valid service from date (inpatient) or the statement covers from date (outpatient). EDIT 089 - DATE OF SURGERY > SERVICE/STATEMENT THRU DATE This edit is posted to an inpatient (claim type 01) or outpatient (claim type 03) claim if there is a valid surgical procedure code and surgery date is greater than a valid service thru date (inpatient) or the statement covers thru date (outpatient). EDIT 100 - NO REVENUE CODE FOUND EXCEPT 001 This edit is posted to an inpatient (claim type 01), outpatient (claim type 03), or home health (claim type 06) claim if the only occurrence of revenue code data found was revenue code 001. This edit is also posted to an inpatient claim if the revenue code is not numeric or if the revenue code is equal to 000 but there are revenue units and/or revenue charges greater than zero. EDIT 101 - ORIGINAL RECIPIENT ID HAS BEEN CHANGED DUE TO LINK/UNLINK This EOB is posted on a claim when the original recipient ID has been updated. This is the result of a link/unlink process having been performed on the Recipient Master File.


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EDIT 102 - TOOTH SURFACE MISSING/INVALID This edit is posted to a dental (claim type 11) encounter claim if an occurrence of tooth surface is not spaces and the previous occurrence is spaces, or if the tooth surface value does not match one of the following values: M - Mestal I - Incisal B - Buccal O - Occlusal D - Distal L - Lingual EDIT 103 - ORIG RECIP ID CORRECTED DUE TO LINK/UNLINK SPECIAL PROCESS This edit was applied to any claim identified as incorrectly updated during the normal Link/Unlink process in error. A special correction to claims was run and edit 101 was replaced with edit 103 to identify claims corrected. EDIT 107 - ENC CATEGORY OF SERVICE MISSING/INVALID This edit is posted for any encounter claim if the category of service billed by the HMO is missing or not one of the following values:

COS Description 01A - Primary Care Physician 01B - Nurse Practitioner 01C - Physician Assistant 01D - Specialty Physician 002 - EPSDT 003 - Inpatient Hospital 004 - Outpatient Hospital 005 - Laboratory 006 - Radiology 007 - Prescription Drugs 008 - Family Planning 009 - Rehabilitation Services 010 - Podiatrist Services 011 - Chiropractor Services 012 - Optometrist Services 013 - Optical Appliances 014 - Hearing Aids 015 - Home Health Agency Services 016 - Hospice Services 018 - Medical Supplies 019 - Prosthetics & Othotics 020 - Dental Services 021 - Organ Transplant 022 - Transportation


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EDIT 108 - DRG OUTLIER INDICATOR MISSING/INVALID This edit is posted to inpatient (claim type 01) encounter claims if a DRG code is billed and the DRG outlier code is not one of the following values:

Spaces - Optional Field C - Clinical N - Inlier H - High Trim V - Low Volume L - Low Trim S - Same Day Stay T - Transfer

EDIT 109 - ENCOUNTER COS INVALID FOR CLAIM TYPE This edit is posted to any encounter claim if the category of service billed by the HMO is invalid for the claim type billed. The valid claim type for each category of service is as follows:

COS Description CT 01A Primary Care Physician 04 01B Nurse Practitioner 04 01C Physician Assistant 04 01D Specialty Physician 04 002 EPSDT 04 003 Inpatient Hospital 01 004 Outpatient Hospital 03 005 Laboratory 04 006 Radiology 04 007 Prescription Drugs 12 008 Family Planning 04 009 Rehabilitation Services 04 010 Podiatrist Services 04 011 Chiropractor Services 04 012 Optometrist Services 04 013 Optical Appliances 08 014 Hearing Aids 04 015 Home Health Agency Services 06 016 Hospice Services 04 018 Medical Supplies 04 019 Prosthetics & Othotics 04 020 Dental Services 11 021 Organ Transplant 04 022 Transportation 07

EDIT 110 - ENC TAXONOMY MISSING/INVALID This edit is posted to any encounter claim if the claim is a professional claim and the taxonomy field is not populated or is invalid. EDIT 123 - MEDICAL RECORD NUMBER MISSING/INVALID This edit is posted to an inpatient (claim type 01), outpatient (claim type 03), or home health (claim type 06) encounter claim if the medical record number is spaces or less than four characters in length.


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EDIT 124 - PATIENT ACCOUNT NUMBER MISSING/INVALID This edit posted to any encounter claim if the patient account number is spaces, zeros, or is less than four characters in length. EDIT 125 - PHARMACY REFILL INDICATOR MISSING/INVALID This edit is posted to a pharmacy (claim type 12) encounter claim if the refill indicator is missing, spaces, or not one of the following values:

00 New prescription 01-99 Number of refills

EDIT 126 - COMPOUND DRUG INDICATOR MISSING/INVALID This edit is posted to a pharmacy (claim type 12) encounter claim if the compound drug indicator is missing, spaces, or not one of the following values:

Y Yes N No

EDIT 127 - NATIONAL DRUG CODE MISSING/INVALID This edit is posted to a pharmacy (claim type 12) encounter claim if the compound drug indicator is not equal to 'Y', and the NDC either missing, non-numeric, zeros, or the first five positions are zeros. EDIT 130 - PHARMACY DAYS SUPPLY MISSING/INVALID This edit is posted to a pharmacy (claim type 12) encounter claim if the days supply is missing, non-numeric, or zeros. EDIT 131 - PRESCRIPTION NUMBER MISSING/INVALID This edit is posted to a pharmacy (claim type 12) encounter claim if the prescription number is missing, spaces, or zeros. EDIT 133 - EMPLOYMENT RELATED INDICATOR MISSING/INVALID This edit is posted any encounter claim if the patient employment related indicator is missing or not one of the following values:

Y Yes N No

EDIT 135 - CURRENT EXAM DATE MISSING/INVALID This edit is posted to a vision (claim type 08) encounter claim if the current exam date is invalid or missing. In other words, the current exam date is non-numeric, equal to zeros, or failed standard date editing routines. EDIT 136 - PREVIOUS EXAM DATE INV This edit is posted to a vision (claim type 08) encounter claim if the previous exam date is invalid. In other words, the previous exam date is non-numeric, other than spaces, or failed standard date editing routines. EDIT 138 - ACCIDENT INDICATOR MISSING/INVALID This edit is posted any encounter claim if the accident indicator is missing or not one of the following values:

Y Yes N No


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EDIT 139 - EPSDT INDICATOR INVALID This edit is posted to a professional (claim type 04), transportation (claim type 07), vision (claim type 08), and dental (claim type 11) encounter claim if the EPSDT indictor is not one of the following values:

Y Yes N No

EDIT 141 - PLACE OF SERVICE MISSING/INVALID This edit is posted to a professional (claim type 04), vision (claim type 08), and dental (claim type 11) encounter claim if the place of service is missing or not one of the following values:

0 - Emergency Room 1 - Doctor's Office 2 - Patient's Home 3 - Inpatient Hospital 4 - Boarding Home 5 - Skilled Nursing Home 6 - Independent Laboratory 7 - Outpatient Hospital 8 - Clinic 9 - Other

Note: Value 9 (Other) can include day care facility, night care facility, nursing home, ambulance, other

medical surgical facility, residential treatment center, specialized treatment facility, and independent kidney treatment center.

EDIT 142 - ORIGIN CODE MISSING/INVALID This edit is posted to a transportation (claim type 07) encounter claim if the origin code is missing or not one of the following values:

0 - Emergency room 1 - Doctor's office 2 - Patient's home 3 - Inpatient hospital 4 - Boarding home 5 - Nursing facility 6 - Independent laboratory 7 - Outpatient hospital 8 - Clinic 9 - Other


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EDIT 143 - DESTINATION CODE MISSING/INVALID This edit is posted to a transportation (claim type 07) encounter claim if the destination code is missing or not one of the following values:

0 - Emergency room 1 - Doctor's office 2 - Patient's home 3 - Inpatient hospital 4 - Boarding home 5 - Nursing facility 6 - Independent laboratory 7 - Outpatient hospital 8 - Clinic 9 - Other

EDIT 144 - PATIENT ACCOUNT NUMBER IDENTIFIES HMO-DENIED CLAIM This edit is posted to an encounter claim if the patient account number identifies an HMO-denied claim (i.e., the last/rightmost character of the patient account number is a 'D'). NOTE: Encounters for HMO denied claims submitted on or after June 1, 2013 bypass edits 023 and

024. EDIT 151 - CLAIM CHARGE MISSING/INVALID This edit is posted to any encounter claim if the claim line charge is non-numeric or is less than zero. Note: This amount represents the actual payment made by the HMO to their provider for the service represented on the encounter claim. The HMO is permitted to state a zero amount for those providers that are capitated or receive special incentives/bonuses. However, if zero payment encounter claims are present, the HMO is responsible for providing capitation summary or capitation detail encounter claims. Capitation encounter claims specify a monthly aggregate payment amount (usually the capitated amount) for a specific provider (capitation summary) or provider/recipient combination (capitation detail) and are identified by "SUMRY" or "CAPDT" in the service code field. EDIT 152 - TOTAL CHARGE MISSING/INVALID This edit is posted to any encounter claim if the claim total charge is non-numeric. Note: This amount represents the actual payment made by the HMO to their provider for the service represented on the encounter claim. The HMO is permitted to state a zero amount for those providers that are capitated or receive special incentives/bonuses. However, if zero payment encounter claims are present, the HMO is responsible for providing capitation summary or capitation detail encounter claims. Capitation encounter claims specify a monthly aggregate payment amount (usually the capitated amount) for a specific provider (capitation summary) or provider/recipient combination (capitation detail) and are identified by "SUMRY" or "CAPDT" in the service code field.


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EDIT 153 - CLAIM PAYMENT MISSING/INVALID This edit is posted to any encounter claim if the claim payment amount is equal to 9999999.99. This value indicates that one of the following conditions is found:

(1) a line level payment was not submitted (2) a submitted line level payment amount is greater than 9999999.99 (3) for inpatient claims, the claim payment amount, which is computed as the total of all line level

payment amounts, is greater than 9999999.99 (4) Other Payer ID equal to 'HMO' was not found on a pharmacy encounter claim. (5) For pharmacy encounter claims, the Other Payer Amount submitted with Other Payer ID equal to

'HMO' is a non-numeric amount. NOTE: This amount represents the actual payment made by the HMO to their provider for the services identified on the encounter claim. The HMO is permitted to state a zero amount for those providers that are capitated or receive special incentives or bonuses. However, if zero payment encounter claims are present, the HMO is responsible for providing capitation summary or capitation detail encounter claims. Capitation encounter claims specify a monthly aggregate payment amount (usually the capitated amount) for a specific provider (capitation summary) or provider/recipient combination (capitation detail) and are identified by "SUMRY" or "CAPDT" in the service code field. EDIT 161 - PROCEDURE CODE MISSING/INVALID This edit is posted to outpatient (claim type 03), professional (claim type 04), transportation (claim type 07), vision (claim type 08), and dental (claim type 11) encounter claims if either of the following two conditions is true:

1. The procedure code is spaces, or any character of the five position procedure code is a space. 2. The claim is a HIPAA claim (E-CLM-MEDIA-CDE = 8), the claim service date (E-CLM-SERVICE-

DTE) is 04/01/2004 or later, and the procedure code (E-PROC-CDE) is within the range W0000-Z9999.

Note: For outpatient (claim type 03) encounter claims with non-lab service revenue codes, (i.e. revenue codes other than 300-319 or 380-399), the following applies. System logic will populate a blank procedure code with the HIPAA submitted procedure code when it is non-blank, or value ‘OPxxx’ when it is blank, (where xxx equals the claim revenue code), before applying the above rules.


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EDIT 162 - PROCEDURE CODE MODIFIER MISSING/INVALID This edit is posted if a procedure modifier is not equal to spaces and contains a value that does not meet the following criteria when comparing the claim against the NJMMIS Modifier Table:

a) The modifier exists in the NJMMIS Modifier Table and is defined as valid in the NJMMIS Modifier Table (i.e., the "VALID/INVALID CODE" is equal to "V").

b) The beginning (FROM) date of service and the end (TO) date of service for the claim fall within the

allowable modifier begin (FROM) and end (TO) date range. Modifiers in the NJMMIS Modifier Table can be displayed via NJMMIS on-line inquiry. The following menu options would be selected to access this inquiry function:

a) NJMMIS MAIN MENU - Option 04 ("REFERENCE") b) NJMMIS REFERENCE SUBSYSTEM MENU - Option 12 ("REFERENCE VALID VALUE") c) NJMMIS VALID VALUE AND ASSIGNMENT INQUIRY AND MAINTENANCE MENU - Option 01

("PROC CODE MODIFIER"). EDIT 166 - DIAGNOSIS CODE MISSING/INVALID This edit is posted to an inpatient (claim type 01), outpatient (claim type 03), professional (claim type 04), home health (claim type 06), transportation (claim type 07), or vision (claim type 08) encounter claim, if any of the following is true: ICD9 - The first occurrence of diagnosis codes is spaces. - The first character of any of the diagnosis codes contains a value other than '0' thru '9' or 'V'. - The second or third digit of any of the diagnosis codes contains a value other than '0' thru '9'. - The fifth digit is not a space and the fourth digit is a space. For ICD10 diagnosis codes: 1. The first occurrence of diagnosis code is equal to spaces, OR 2. 1st digit is not alphabetic OR 3. 2nd digit is not numeric OR 4. 3rd-7th digits are not alphabetic, numeric or spaces OR 5. Spaces in anywhere but ending digits OR For pharmacy, the edit will be bypassed if a diagnosis code is not present. If a diagnosis code is populated, it will be checked for validity following the same rules defined above. EDIT 167 - DIAGNOSIS CODE MISSING This edit is posted to an inpatient (claim type 01), outpatient (claim type 03), or home health (claim type 06) encounter claim if the current occurrence of diagnosis codes is not spaces, and a previous occurrence of diagnosis code is spaces.


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EDIT 168 - GESTATION INDICATOR INVALID FOR PROC/DIAG/REV CODES For claim types 01, 03 and 04 having a Gestation Indicator = 'Y' and a Claim Service Date from 10-01-2000, this edit will post if one of the following conditions don't exist: Procedure Code equal to: '59400', '59409', '59410', '59412', '59414', '59430', '59510', '59514', '59515', '59525', '59610', '59612', '59614', '59618', '59620', '59622', or '59821' OR Diagnosis Code equal to: '64001', '64081', '64091', '64101', '64111', '64121', '64131', '64181', '64191', '64201', '64211', '64221', '64231', '64241', '64251', '64261', '64271', '64291', '64202', '64212', '64222', '64232', '64242', '64252', '64262', '64272', '64292', '64301', '64311', '64321', '64381', '64391', '64421', '64501', '64511', '64521', '64601', '64611', '64621', '64631', '64641', '64651', '64661', '64671', '64681', '64691', '64612', '64622', '64642', '64652', '64662', '64682', '64701', '64711', '64721', '64731', '64741', '64751', '64761', '64781', '64791', '64702', '64712', '64722', '64732', '64742', '64752', '64762', '64782', '64792', '64801', '64811', '64821', '64831', '64841', '64851', '64861', '64871', '64881', '64891', '64802', '64812', '64822', '64832', '64842', '64852', '64862', '64872', '64882', '64892', '650 ' THRU '65099' '65101', '65111', '65121', '65131', '65141', '65151', '65161', '65181', '65191', '65201', '65211', '65221', '65231', '65241', '65251', '65261', '65271', '65281', '65291', '65301', '65311', '65321', '65331', '65341', '65351', '65361', '65371', '65381', '65391', '65401', '65411', '65421', '65431', '65441', '65451', '65461', '65471', '65481', '65491', '65402', '65412', '65422', '65432', '65442', '65452', '65462', '65472', '65482', '65492', '65501', '65511', '65521', '65531', '65541', '65551', '65561', '65571', '65581', '65591', '65601', '65611', '65621', '65631', '65641', '65651', '65661', '65671', '65681', '65691', '65701', '65801', '65811', '65821', '65831', '65841', '65881', '65891', '65901', '65911', '65921', '65931', '65941', '65951', '65961', '65971', '65981', '65991', '66001', '66011', '66021', '66031', '66041', '66051', '66061', '66071', '66081', '66091', '66101', '66111', '66121', '66131', '66141', '66191', '66201', '66211', '66221', '66231', '66301', '66311', '66321', '66331', '66341', '66351', '66361', '66381', '66391' '664 ' THRU '66499' '66501', '66511', '66531', '66541', '66551', '66561', '66571', '66581', '66591', '66522', '66572', '66582', '66592', '66602', '66612', '66622', '66632', '66702', '66712', '66801', '66811', '66821', '66881', '66802', '66812', '66822', '66882', '66891', '66892', '66901', '66911', '66921', '66931', '66941', '66951', '66961', '66971', '66981', '66991', '66902', '66912', '66922', '66932', '66942', '66982', '66992', '67002', '67101', '67111', '67121', '67131', '67151', '67181', '67191', '67102', '67112', '67122', '67142', '67152', '67182', '67192', '67202', '67301', '67311', '67321', '67331', '67381', '67302', '67312', '67322', '67332', '67382', '67401', '67402', '67412', '67422', '67432', '67442', '67482', '67492', '67501', '67511', '67521', '67581', '67591', '67502', '67512', '67522', '67582', '67592', '67601', '67611', '67621', '67631', '67641', '67651', '67661', '67681', '67691', '67602', '67612', '67622', '67632', '67642', '67652', '67662', '67682', '67692', '677', 'V27', 'V270', 'V271', 'V272', 'V273', 'V274', 'V275', 'V276', 'V277', 'V279' OR Revenue equal to: 720, 722, 724, or 729 For claim types 01, 03 and 04 with a Claim Service Date of 10-01-2000 or greater and a Gestation Indicator not = 'Y', this edit will post if: Procedure Code equal to: 'W9027', 'W9029', or 'W9031'


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EDIT 172 - PAYOR ID MISSING/INVALID This edit is posted to an inpatient (claim type 01), outpatient (claim type 03), or home health (claim type 06) encounter claim if the payor id is missing or not valued with "12" for Medicaid. EDIT 183 - HMO PAYMENT DATE MISSING/ INVALID This edit is posted to an encounter claim if one of the following conditions is found: 1. The HMO payment date was not submitted at either the service line level or the claim level. 2. The HMO payment date was submitted, but is an invalid date. 3. For regular encounters, the HMO payment date is either: A. less than the service end date, or B. equal to or greater than the encounter claim ICN date. 4. For transportation encounters, (claim type 07), from Logisticare, (submitter #7700164), where the HMO

payment date is either:

A. less than the service end date, or B. equal to or greater than the encounter claim ICN date.

5. For capitation summary or capitation detail encounter claims, the HMO payment date is greater than

(older than) one year prior to the service start date. This edit is posted to either original encounter claims or voids of encounter claims, as the HMO payment date in a void indicates the date that the original encounter was voided by the HMO. NOTE: An HMO payment date is required for encounter claims with an HMO payment amount of zero. EDIT 184 - ADJUSTMENT REASON CODE MISSING/INVALID This edit is posted to any encounter claim if the transaction type is valued with "2" (adjustment) and the adjustment reason is not one of the following values:

04 - Claim correction 37 - Insurance recovery, or

The transaction type is valued with "4" (void) and the adjustment reason is not one of the following values:

05 - Void - wrong provider 06 - Void - wrong recipient 07 - Void - service not provided

EDIT 185 - FORMER ICN # MISSING/INVALID This edit is posted to any encounter claim if the transaction type is "2" (adjustment) or "4" (void) and the former ICN field missing, spaces, or zeros, the ICN year is equal to zero, the ICN day is not equal to 001 thru 366, or the ICN batch is equal to zero.


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EDIT 197 - COMPOUND DRUG OR METRIC QUANTITY ERROR This edit is posted to Pharmacy claims only (CT 12). This edit is posted for two reasons as follows: 1. Because the drug/service code (NDC) on the in-coming claim indicates that it’s not a compound, but

the compound code submitted says it is. 2. Because the metric quantity on the in-coming encounter claim is not numeric. Metric quantity must

have ten numeric digits. NOTE: This edit is being posted in POS/createposclm.pc EDIT 206 - BILLING PROVIDER NUMBER NOT ON FILE This edit is posted to any encounter claim if the billing provider number is not matched against the Provider Master File. Note: The billing provider number represents the HMO's Medicaid provider number for encounter claims. EDIT 207 - BILLING PROVIDER INELIGIBLE ON DATE OF SERVICE This edit is posted to any encounter claim if the billing provider number (the HMO submitting the claim) is not eligible on the date of service. EDIT 214 - INVALID NDC OR NDC NOT ON FILE This edit is posted to the claim if the claim has a procedure code:

J0120 thru J9999 Q0144 thru Q0181 Q4079 thru Q4081 Q9945 thru Q9999 Q3025, Q3026, Q2009, Q2017, Q0138, Q0139, Q2043, Q4074, Q2049, Q2050, Q2051

AND 1. NDC code is not numeric or Zero OR 2. The FDB Add Date and FDB Unit Price Date is zero. OR 3. NDC is not found on the Drug Master File (EF200V1) OR 4. Either or both the FDB Add Date or the FDB Unit Price Date are > zero and the Claim Service Date is < FDB Add Date or FDB Unit Price Date (use the lesser of the 2 dates) OR 5. NDC has an active E542 Auto Error Code for the Claim Service Date Number 5 was removed from the POS edit logic with TSU15506/MOD 9686 in November 2017. This edit was changed to deny effective 4/28/2017.


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EDIT 215 - PROCEDURE/NDC COMBINATION IS INVALID OR NOT ON FILE 1. This edit is posted to the claim if the procedure code and NDC combination does not exist on the

PROC/NDC CROSS REFERENCE FILE OR 2. The Encounter claim Service Date does not fall within the XREF Begin Date and XREF End date for

any of the 20 possible ranges for which the PROC/NDC relationship has been defined. NOTE: The claims NDC (Professional) is stored in E-PR-NDC-CDE. The claims NDC (Outpatient) is stored in E-OP-NDC-CDE. EXCEPTION: This edit is bypassed for the following procedure codes: J3490, J3590, and J9999. These are considered unlisted procedures which are used for new drugs that are not assigned a specific 'J' code. EDIT 217 - TAXONOMY CODE IS MISSING FOR THE BILLING PROVIDER This edit is posted if the Billing Provider's Taxonomy Code is missing and the crosswalk of the NPI to a single Medicaid Provider ID was unsuccessful. Exceptions:

1. Claim media code is not "8" (HIPAA) 2. Electronic claims processed (ICNed) before May 23, 2008 3. Non-covered entities (providers not required to obtain NPIS) 4. Recycles (Saturday or Sunday ICN Julian Date) of claims processed before May 23, 2008 5. Claims with Summary Procedure Codes (first 5 characters are 'SUMRY') 6. Voided claims

EDIT 218 - TAXONOMY CODE IS INVALID FOR THE BILLING PROVIDER This edit is posted if the billing provider's taxonomy code is present (must be greater than spaces and not zero) but the taxonomy code is not a valid taxonomy code. To verify a taxonomy code, use CICS Reference option 23 (FFS only) and enter a specific value in the taxonomy code field. Exceptions:

1. Claim media code is not "8" (HIPAA) 2. Electronic claims processed (ICNed) before May 23, 2008 3. Claims with Summary Procedure Codes (first 5 characters are 'SUMRY') 4. Voided claims


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EDIT 219 - TAXONOMY CODE IS MISSING FOR SERVICE PROVIDER This edit is posted if the Servicing Provider's Taxonomy Code is missing and the Crosswalk of the NPI to a single Medicaid Provider ID was unsuccessful. Exceptions:


EDIT 220 - TAXONOMY CODE IS INVALID FOR SERVICE PROVIDER This edit is posted if the servicing provider's taxonomy code is present (must be greater than spaces and not zero) but the taxonomy code is not a valid taxonomy code. To verify a taxonomy code, use CICS Reference option 23 (FFS only) and enter a specific value in the taxonomy code field. Exceptions:

1. Claim media code is not "8" (HIPAA) 2. Electronic claims processed (ICNed) before May 23, 2008 3. Non-covered entities (providers not required to obtain NPIS) 4. Claims with Summary Procedure Codes (first 5 characters are 'SUMRY') 5. Voided claims

EDIT 221 - NPI IS MISSING FOR SERVICE/RENDERING PROVIDER This edit is posted if the servicing providers NPI was not submitted on the claim. The NPI must be greater than spaces and not equal to zeros. Exceptions:

1. Claim media code is not "8" (HIPAA) 2. Electronic claims processed (ICNed) before May 23, 2008 3. Non-covered entities (providers not required to obtain NPI's) 4. Recycles (Saturday or Sunday ICN Julian Date) of claims processed before May 23, 2008 5. Claims with Summary Procedure Codes (first 5 characters are 'SUMRY') 6. Voided claims 7. Claims with Service Date after June 30, 2011 AND

Claim Type 07 (Transportation) AND Submitter is Logisticare (Submitter ID 7700164)

8. Claims with Service Date after June 30, 2014 AND Claim Proc Code/Proc Modifier is one of the following: S5111 S5120 S5121 S5165 S5170 T1005 T1028 T2002 T2003 T2038 T2038U6 T2039 T2039U7


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EDIT 222 - NPI IS INVALID FOR SERVICE/RENDERING PROVIDER This edit is posted if the servicing provider's NPI was submitted on the claim (the NPI was not spaces or zeros), but the NPI was not numeric or did not have a valid NPI check digit. Exceptions:


EDIT 223 - NPI IS MISSING FOR THE ATTENDING PROVIDER This edit is posted if the attending provider's NPI was not submitted on the claim. The NPI must be greater than spaces and not equal to zeros. Exceptions:

1. Claim media code is not "8" (HIPAA) 2. Electronic claims processed (ICNed) before May 23, 2008 3. Non-covered entities (providers not required to obtain NPIS) 4. Recycles (Saturday or Sunday ICN Julian Date) of claims processed before May 23, 2008 5. Claims with Summary Procedure Codes (first 5 characters are 'SUMRY') 6. Voided claims 7. Outpatient 5010 claim with revenue code 540-549.

EDIT 224 - NPI IS INVALID FOR THE ATTENDING PROVIDER This edit is posted if the attending provider's NPI was submitted on the claim (the NPI is not spaces or zeros), but the NPI was not numeric or did not have a valid NPI check digit. Exceptions:

1. Claim media code is not "8" (HIPAA) 2. Electronic claims processed (ICNed) before May 23, 2008 3. Non-covered entities (providers not required to obtain NPIs) 4. Claims with Summary Procedure Codes (first 5 characters are 'SUMRY') 5. Voided claims

EDIT 225 - NPI IS MISSING FOR THE REFERRING PROVIDER Professional and Inpatient Encounter claims This edit is posted if a valid referring EIN/SSN was submitted (numeric and greater than zero) on an Inpatient or professional Encounter claim, but the referring provider's NPI was not submitted (is spaces or zeroes). Exceptions: 1. Claim media code is not "8" (HIPAA) 2. Electronic claims processed (ICNed) before May 23, 2008 3. Non-covered entities (providers not required to obtain NPIS) 4. Recycles (Saturday or Sunday ICN Julian Date) of claims processed before May 23, 2008 5. Claims with Summary Procedure Codes (first 5 characters are 'SUMRY') 6. Voided claims


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EDIT 226 - NPI IS INVALID FOR THE REFERRING PROVIDER This edit is posted if the referring provider's NPI was submitted on the claim (the NPI is not spaces or zeros), but the NPI was not numeric or did not have a valid NPI check digit. Exceptions:


This edit will apply to Inpatient claims where the ICN Julian Date is on or after October 12, 2015 where the referring provider's NPI was submitted, but the NPI was not numeric. EDIT 227 - NPI IS MISSING FOR THE OPERATING PROVIDER Inpatient Encounter claims This edit is posted if a valid operating EIN/SSN was submitted (numeric and greater than zero) on an Inpatient Encounter claim, but the operating provider's NPI was not submitted (is spaces or zeroes). Exceptions: 1. Claim media code is not "8" (HIPAA) 2. Electronic claims processed (ICNed) before May 23, 2008 3. Non-covered entities (providers not required to obtain NPIS) 4. Recycles (Saturday or Sunday ICN Julian Date) of claims processed before May 23, 2008 5. Claims with Summary Procedure Codes (first 5 characters are 'SUMRY') 6. Voided claims This edit will apply to Inpatient claims where the ICN Julian Date is on or after October 12, 2015 where the operating provider's NPI was submitted. For inpatient claims with ICN Julian date prior to October 12, 2015, edit 231 for 'other' will continue to be posted when the 'Other' providers NPI is not greater than spaces or is equal to zeros. EDIT 228 - NPI IS INVALID FOR THE OPERATING PROVIDER This edit is posted if the operating provider's NPI was submitted on the claim (the NPI is not spaces or zeros), but the NPI was not numeric or did not have a valid NPI check digit. Exceptions:


This edit will apply to Inpatient claims where the ICN Julian Date is on or after October 12, 2015 where the operating provider's NPI was submitted but is not numeric or has an invalid check digit. For inpatient claims with ICN Julian date prior to October 12, 2015, edit 232 for 'other' NPI will continue to be posted when the NPI is not numeric or has an invalid check digit.


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EDIT 229 - NPI IS MISSING FOR BILLING PROVIDER This edit is posted if the billing provider's NPI was not submitted on the claim. The NPI must be greater than spaces and not equal to zeros. Exceptions:

1. Claim media code is not "8" (HIPAA) 2. Electronic claims processed (ICNed) before May 23, 2008 3. Non-covered entities (providers not required to obtain NPIS) 4. Recycles (Saturday or Sunday ICN Julian Date) of claims processed before May 23, 2008 5. Claims with Summary Procedure Codes (first 5 characters are 'SUMRY') 6. Voided claims 7. Claims with Service Date after June 30, 2014 AND Claim Proc Code/Proc Modifier is one of the

following: S5111, S5120, S5121, S5165, S5170, T1005, T1028, T2002 T2003, T2038, T2038U6, T2039, T2039U7.

EDIT 230 - NPI IS INVALID FOR BILLING PROVIDER This edit is posted if the billing provider's NPI was submitted on the claim (the NPI was not spaces or zeros), but the NPI was not numeric or did not have a valid NPI check digit. Exceptions:


EDIT 231 - NPI IS MISSING FOR OTHER PROVIDER Outpatient Encounter Claims This edit is posted if a valid 'Other' EIN/SSN was submitted (numeric and greater than zero) on an Outpatient Encounter claim, but the 'Other' provider's NPI was not submitted (is spaces or zeroes). Exceptions: 1. Claim media code is not "8" (HIPAA) 2. Electronic claims processed (ICNed) before May 23, 2008 3. Non-covered entities (providers not required to obtain NPIS) 4. Recycles (Saturday or Sunday ICN Julian Date) of claims processed before May 23, 2008 5. Claims with Summary Procedure Codes (first 5 characters are 'SUMRY') 6. Voided claims EDIT 232 - NPI IS INVALID FOR OTHER PROVIDER This edit is posted if the other provider's NPI was submitted on the claim (the NPI was not spaces or zeros), but the NPI was not numeric or did not have a valid NPI check digit. Exceptions:



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EDIT 233 - NPI IS MISSING FOR PRESCRIBING PROVIDER This edit is posted if the prescribing provider's NPI was not submitted on the claim. The NPI must be greater than spaces and not equal to zeros. Exceptions:


EDIT 234 - NPI IS INVALID FOR PRESCRIBING PROVIDER This edit is posted if the prescribing provider's NPI was submitted on the claim (the NPI was not spaces or zeros), but the NPI was not numeric or did not have a valid NPI check digit. Exceptions:


EDIT 235 - NPI NOT ON FILE FOR SERVICE/RENDERING PROVIDER This edit is posted to the claim if the providers NPI was submitted on the claim but the return code from the NPI MAPPING MODULE indicated a not found condition. EDIT 236 - ZIP CODE MISSING OR INVALID This edit is posted if the service providers ZIPCODE is not numeric or the ZIPCODE is equal to zeros. Exceptions:

1. Claim media code is not "8" (HIPAA) 2. Electronic claims processed (ICNed) before May 23, 2008 3. Claims with Summary Procedure Codes (first 5 characters are 'SUMRY') 4. Voided claims

EDIT 237 - NPI NOT CROSSWALKED - SERV/REND This edit is posted, if the call to the NPI MAPPING MODULE determined that the NPI submitted on the claim was not on the NPI Mapping Table, or the NPI was on the NPI Mapping Table, but the MAPPING MODULE was unable to return a Provider ID based on the search criteria from the claim of NPI, Zip Code and Taxonomy Code, and a default provider was not found. Exceptions:



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EDIT 238 - PROVIDER NOT MATCHED-SERV/REND This edit is posted if the provider number submitted on the claim is not equal to the provider number on the NJMMIS NPI database. This is determined from a call to the NPI MAPPING MODULE in order to obtain a Medicaid Provider ID. Exceptions:


EDIT 240 - NPI NOT CROSSWALKED - BILLING This edit is posted, if the call to the NPI MAPPING MODULE determined that the NPI submitted on the claim was not on the NPI Mapping Table, or the NPI was on the NPI Mapping Table, but the MAPPING MODULE was unable to return a Provider ID based on the search criteria from the claim of NPI, Zip Code and Taxonomy Code, and a default provider was not found. Exceptions:


EDIT 241 - PROVIDER NOT MATCHED-BILLING This edit is posted if the provider number submitted on the claim is not equal to the provider number on the NJMMIS NPI database. This is determined from a call to the NPI MAPPING MODULE in order to obtain a Medicaid Provider ID. Exceptions:



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EDIT 243 - NPI NOT CROSSWALKED-ATTENDING This edit is posted, if the call to the NPI MAPPING MODULE determined that the NPI submitted on the claim was not on the NPI Mapping Table, or the NPI was on the NPI Mapping Table, but the MAPPING MODULE was unable to return a Provider ID based on the search criteria from the claim of NPI, Zip Code and Taxonomy Code, and a default provider was not found. Exceptions:


EDIT 244 - PROVIDER NOT MATCHED-ATTENDING This edit is posted if the provider number submitted on the claim is not equal to the provider number on the NJMMIS NPI database. This is determined from a call to the NPI MAPPING MODULE in order to obtain a Medicaid Provider ID. Exceptions:


EDIT 246 - NPI NOT CROSSWALKED - REFERRING This edit is posted, if the call to the NPI MAPPING MODULE determined that the NPI submitted on the claim was not on the NPI Mapping Table, or the NPI was on the NPI Mapping Table, but the MAPPING MODULE was unable to return a Provider ID based on the search criteria from the claim of NPI, Zip Code and Taxonomy Code, and a default provider was not found. Exceptions:


This edit will apply to Inpatient claims where the ICN Julian Date is on or after October 12, 2015 where the referring provider's NPI was submitted but could not be crosswalked to a Provider ID. For inpatient claims with ICN Julian prior to October 12, 2015, No referring provider edits are posted.


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EDIT 247 - PROVIDER NOT MATCHED-REFERRING This edit is posted if the provider number submitted on the claim is not equal to the provider number on the NJMMIS NPI database. This is determined from a call to the NPI MAPPING MODULE in order to obtain a Medicaid Provider ID. Exceptions:


EDIT 248 - SURGICAL PROCEDURE CODE NOT ON FILE This edit is posted to an inpatient (claim type 01) or outpatient (claim type 03) encounter claim if the primary or secondary procedure code is not on the procedure code file. EDIT 253 - PROCEDURE NOT VALID ON DATE(S) OF SERVICE The procedure code must be valid on the date of service. For inpatient claims with a surgical procedure code, the Claim Service Through Date must be on or within the begin/end dates of the surgical procedure code. EDIT 254 - DRG CODE AND AGE RESTRICTED This edit is posted to enforce age restrictions on Encounter maternity claims. The edit will post under the following conditions:

1. Claim Type = 01, 2. Patient Calculated Age is not in the range of 11-50.

EDIT 255 - DRG CODE AND SEX RESTRICTION This edit is posted to enforce sex restrictions on Encounter maternity claims. The edit will post under the following conditions:

1. Claim Type = 01, 2. Recipient Sex Code not = F.

EDIT 259 - PROCEDURE CODE NOT ON FILE The edit is posted to any encounter claim if the procedure code billed or derived from the submitted revenue code is not on the procedure code file.


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EDIT 261 - NPI NOT CROSSWALKED - OPERATING This edit is posted, if the call to the NPI MAPPING MODULE determined that the NPI submitted on the claim was not on the NPI Mapping Table, or the NPI was on the NPI Mapping Table, but the MAPPING MODULE was unable to return a Provider ID based on the search criteria from the claim of NPI, Zip Code and Taxonomy Code, and a default provider was not found. Exceptions:


This edit will apply to Inpatient claims where the ICN Julian Date is on or after October 12, 2015 where the operating provider's NPI was submitted but could not be crosswalked to a Provider ID. For inpatient claims with ICN Julian prior to October 12, 2015, edit 264 for 'other' will continue to be posted when the NPI could not be crosswalked. EDIT 262 - PROVIDER NOT MATCHED-OPERATING This edit is posted if the provider number submitted on the claim is not equal to the provider number on the NJMMIS NPI database. This is determined from a call to the NPI MAPPING MODULE in order to obtain a Medicaid Provider ID. Exceptions:


EDIT 263 - NON-COVERED SERVICE FOR SPECIAL PROGRAM CODE This edit is posted to any encounter claim if it is determined that the recipient is enrolled in either special program code 98 or 99 for any of the dates covered by the claim admit date/claim service date, through claim service date thru.


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EDIT 264 - NPI NOT CROSSWALKED - OTHER This edit is posted, if the call to the NPI MAPPING MODULE determined that the NPI submitted on the claim was not on the NPI Mapping Table, or the NPI was on the NPI Mapping Table, but the MAPPING MODULE was unable to return a Provider ID based on the search criteria from the claim of NPI, Zip Code and Taxonomy Code, and a default provider was not found. Exceptions:


EDIT 265 - PROVIDER NOT MATCHED-OTHER This edit is posted if the provider number submitted on the claim is not equal to the provider number on the NJMMIS NPI database. This is determined from a call to the NPI MAPPING MODULE in order to obtain a Medicaid Provider ID. Exceptions:


EDIT 267 - NPI NOT CROSSWALKED - PRESCRIBING This edit is posted, if the call to the NPI MAPPING MODULE determined that the NPI submitted on the claim was not on the NPI Mapping Table, or the NPI was on the NPI Mapping Table, but the MAPPING MODULE was unable to return a Provider ID based on the search criteria from the claim of NPI, Zip Code and Taxonomy Code, and a default provider was not found. Exceptions:



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EDIT 268 - PROVIDER NOT MATCHED-PRESCRIBING This edit is posted if the provider number submitted on the claim is not equal to the provider number on the NJMMIS NPI database. This is determined from a call to the NPI MAPPING MODULE in order to obtain a Medicaid Provider ID. Exceptions:


EDIT 269 - ATTENDING NPI SAME AS BILLING/SERVICING NPI This edit is posted if the attending NPI is the same as the billing and/or servicing NPI. Exceptions:

1. Claim media code is not "8" (HIPAA) 2. Electronic claims processed (ICNed) before May 23, 2008 3. Recycles (Saturday or Sunday ICN Julian Date) of claims processed before May 23, 2008 4. Voided claims

EDIT 270 - REFERRING NPI SAME AS BILLING/SERVICING NPI This edit is posted if the referring NPI is submitted and is the same as the billing and/or servicing NPI. This edit only applies to Inpatient claims with an ICN Julian date on or after October 12, 2015. Exceptions: 1. Claim media code is not "8" (HIPAA) 2. Electronic claims processed (ICNed) before May 23, 2008 3. Recycles (Saturday or Sunday ICN Julian Date) of claims processed before May 23, 2008 4. Voided claims EDIT 271 - OTHER NPI SAME AS BILLING/SERVICING NPI This edit is posted if the other NPI is the same as the billing and/or servicing NPI. Exceptions:


EDIT 272 - PRESCRIBING NPI SAME AS BILLING/SERVICING NPI This edit is posted if the prescribing NPI is the same as the billing and/or servicing NPI. Exceptions:



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EDIT 281 - OPERATING 1 NPI SAME AS BILLING/SERVICING NPI This edit is posted if the operating NPI is submitted and is the same as the billing and/or servicing NPI. This edit only applies to Inpatient claims with an ICN Julian date on or after October 12, 2015. Exceptions: 1. Claim media code is not "8" (HIPAA) 2. Electronic claims processed (ICNed) before May 23, 2008 3. Recycles (Saturday or Sunday ICN Julian Date) of claims processed before May 23, 2008 4. Voided claims EDIT 289 - ADMITTING DIAGNOSIS CODE NOT ON FILE This edit is posted to an inpatient encounter claim if the admitting diagnosis code is not found on the NJMMIS diagnosis master file. EDIT 296 - DIAGNOSIS CODE NOT ON FILE The edit is posted to an inpatient (claim type 01), outpatient (claim type 03), Professional (claim type 04), home health (claim type 06), transportation (claim type 07), vision (claim type 08), or pharmacy (claim type 12) encounter claim, if the diagnosis code is not on the diagnosis master file for the ICD version indicated. Or Claim Service Date Thru (Claim Service Date From for DME) is not on or within the effective/end dates of the diagnosis code. Diagnosis codes will not be found on the file if the ICD Version indicates 9 but the diagnosis code is ICD10 and vice versa. ICD10 diagnosis codes will not be found on the file if a more specific diagnosis code exists. (For example, 3 digit code A00 is not found because A000, A001 and A009 are more specific and should be used instead.) EDIT 297 - BILLING ZIP CODE IS MISSING OR INVALID This edit is posted if the billing provider's ZIPCODE is not numeric or the ZIPCODE is greater than zeros. Exceptions:

1. Claim media code is not "8" (HIPAA) 2. Electronic claims processed (ICNed) before May 23, 2008 3. Recycles (Saturday or Sunday ICN Julian Date 4. Voided claims

NOTE: This edit is applied only to version 5010 HIPAA claims.


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EDIT 298 - TAXONOMY CODE IS INVALID FOR ATTENDING PROVIDER This edit is posted if the attending provider's taxonomy code is present (must be greater than spaces and not zero) but the taxonomy code is not a valid taxonomy code. To verify a taxonomy code, use CICS Reference option 23 (FFS only) and enter a specific value in the taxonomy code field. Exceptions:


NOTE: This edit is applied only to version 5010 HIPAA claims. EDIT 299 - TAXONOMY CODE IS INVALID FOR REFERRING PROVIDER This edit is posted if the referring provider's taxonomy code is present (must be greater than spaces and not zero) but the taxonomy code is not a valid taxonomy code. To verify a taxonomy code, use CICS Reference option 23 (FFS only) and enter a specific value in the taxonomy code field. Exceptions:


NOTE: This edit is applied only to version 5010 HIPAA claims.


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EDIT 300 - MAXIMUM DAILY DOSAGE EXCEEDED: CHECK DRUG QTY This edit is posted for: 1 - Professional claims 2 - that have an injectable procedure code - see below 3 - that have a NDC on the Maximum Daily Dosage File for the claims date of service that has been exceeded

by the NDC- Metric Quantity reported on the claims. OR 1 - Outpatient claims 2 - that have a revenue code = 631 thru 637 or 25X 3 - that have an injectable procedure code - see below 4 - that have a NDC on the Maximum Daily Dosage File for the claims date of service that has been exceeded

by the NDC- Metric Quantity reported on the claims.

- Injectable Procedure Code values J0120 thru J9999 Q0138 Q0139 Q0144 thru Q0181 Q2043 Q2049 Q2050 Q2051 Q4074 Q4079 thru Q4081 Q9945 thru Q9999 Q3025, Q3026, Q2009, Q2017

EDIT 301 - RECIPIENT INELIGIBLE ON DATES OF SERVICE This edit is posted to any encounter claim if the recipient is not eligible on date of service. EDIT 310 - HMO SENT 'M' TO REQUEST MEDIA 7 KICK PAYMENT AND MMIS PAID This EOB edit is posted if the following are true: a. The encounter was submitted with an 'M' following the Patient Account Number to indicate that the

HMO expected to be reimbursed for the drug or maternity/delivery,

And

b. The MMIS did generate a Media 7 reimbursement claim to the HMO. NOTE: Media 7 reimbursement claims are only generated for Pharmacy CT 12, drug in Professional CT

04, or Inpatient CT 01 Maternity/Delivery.


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EDIT 311 - HMO SENT 'M' TO REQUEST MEDIA 7 REIMBURSEMENT CLAIM NOT ELG This EOB edit is posted for Pharmacy CT 12, Inpatient Hospital CT 01 or Professional drug claims, Claim Type 04 if the following are true: a. The encounter was submitted with an 'M' following the

Patient Account Number to indicate that the HMO expected to be reimbursed for the drug or maternity/delivery,

And

b. The MMIS did NOT generate a Media 7 reimbursement

claim to the HMO. HMO ACTION: Review the claim for other posted edits to determine the reason the Media 7 was not

generated. EDIT 312 - MEDIA 7 CONFLICT RECIPIENT MHC PAYMENT CODE MISSING/INVAL This EOB edit is posted for Pharmacy CT 12, Inpatient Hospital CT 01 or Professional drug claims, Claim Type 04 if the following are true: a. The encounter was submitted for an reimbursable drug

And

b. The MMIS did NOT generate a Media 7 reimbursement

claim to the HMO because the appropriate MHC Payment Code was not found for the service: Blood products MHC Payment Code:

E, F, G, I, J, K, L, R, T, V, X, Z, 3

HIV/AIDS Medication MHC Payment Code:

A, B, C, E, G, H, I, J, L, P, Q, T, U, V, W, X, 2

High Cost Drugs MHC Payment Code:

1, 2, 3, 4

HMO ACTION: Review the drug and MHC Payment Code combination. EDIT 317 - INVALID/MISSING METRIC QUANTITY This edit is posted to the claim when the metric decimal quantity is invalid, missing or zero. This edit was changed to deny effective 4/28/2017.


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EDIT 319 - MISSING OR INVALID PRESENT ON ADMISSION INDICATOR This edit will be posted to Encounter inpatient claims with Service date thru on or after October 12, 2015, patient status is not '30' on the Service thru date and a Present on Admission Indicator (POA) was not submitted, but the corresponding submitted diagnosis is not exempt from reporting. A POA may be blank on a HIPAA claim, as long as the corresponding diagnosis is exempt from reporting. A blank POA on a HIPAA claim will be changed to a '1' for processing in claims front end. A '1' should not be submitted. The valid values that may be submitted on a HIPAA claim are as follows: N = Not present at time of admission U = Undetermined if the condition was present at the time of admission W = Clinically undetermined Y = Present at the time of admission Blank = Unreported If a POA indicator of '1' is submitted, the claim will be rejected. In preprocessor; however, if a diagnosis is submitted and no corresponding valid (N, U, W or Y) POA is submitted, a value of '1' will be used to populate the POA for claims processing purposes, and the corresponding diagnosis must be exempt from reporting, or edit 319 will post. EDIT 320 - POA INDICATOR HAS NO CORRESPONDING DIAGNOSIS CODE This edit will be posted to Encounter inpatient claims with Service date thru on or after October 12, 2015 when the recipient is not active on Service date thru (HNI-PAT-STATUS not = 30) and the claim is submitted with Present on Admission indicator that does not have a corresponding diagnosis code. EDIT 321 - RECIPIENT NUMBER NOT ON FILE This edit is posted to any encounter claim if the recipient is not on the recipient master file.


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EDIT 322 - CLAIM UOM INVALID OR NOT=NDC UOM - SEE WWW.NJMMIS.COM For medical injectable claims, the valid unit of measure submitted on the claim must be one of the following:

UN - UNITS ML - MILLILITERS GR - GRAMS If any other value is submitted, the edit is posted.

In addition, the above values must correspond to the Drug Form Code Value (on DRUGMSTR) for the submitted NDC:

FORM TRANSLATED CODE VALUE

1 UN 2 ML 3 GR

For example, if the claim was submitted with ML, then the Drug Form Code for the NDC must equal 2. If there is a mismatch between the claim and the DRUGMSTR, the edit is posted. Quantity should be consistent with Unit Of Measure. Edit was set to deny on 4/28/2017. EDIT 323 - MAXIMUM DAILY DOSAGE NOT FOUND This edit is posted for: 1 - Professional claims 2 - that have an injectable procedure code - see below 3 - that DO NOT have an NDC on the Maximum Daily Dosage File for the claims date of service. OR 1 - Outpatient claims 2 - that have a revenue code = 631 thru 637 or 25X 3 - that have an injectable procedure code - see below 4 - that DO NOT have an NDC on the Maximum Daily Dosage File for the claims date of service. - Injectable Procedure Code values J0120 thru J9999

Q0138 Q0139 Q0144 thru Q0181 Q2043 Q2049 Q2050 Q2051 Q4074 Q4079 thru Q4081 Q9945 thru Q9999 Q3025, Q3026, Q2009, Q2017


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EDIT 328 - BILL OP DRUG CLAIMS USING REVENUE CODES 631 THRU 637 OR 25X For outpatient medical injectable claims, the revenue code submitted on the claim must be 631 thru 637 or in 25x range. If any other revenue code is submitted, the edit is posted. This edit was set to deny on 4/28/2017. EDIT 329 - HEALTHCARE PROVIDER FEDERALLY EXCLUDED FROM NJMM PARTICIPATION This edit is posted to claims where any of the NPI entries are on the Federally excluded database. EDIT 330 - METRIC QUANTITY INCORRECTLY REPORTED FOR DRUG BILLED This edit is posted to:

1. Medical Injectable Professional and Outpatient (CT 03, 04) claims if two times the claim charge is less than the calculated drug cost allowance.

*NOTE: Tell the provider to verify the metric quantity. Edit was set to deny on 4/28/2017. EDIT 334 - HEALTHCARE PRVDR FEDERALLY EXCLUDED FROM NJMM PARTICIPATION This edit is posted to claims where the provider has a cancel reason code of 10 or 11. EDIT 339 - RECIPIENT ENROLLMENT IN MULTIPLE MANAGED CARE PLANS This edit is posted to an encounter claim if any combination of two or more active recipient plan enrollment segments are found for PACE, D-SNP, or HMO Managed Care that cover any part of the encounter claim service period. NOTE: The segment combinations must include at least two of the three plans listed above. EDIT 344 - BIRTH WEIGHT ON CLAIM AND DRG CONFLICT This edit is posted when - The original DRG is a newborn DRG equal to one of the following DRG listed below - The birth weight submitted on the claim for the original newborn DRG does not conform to the allowed

birth weights defined below. 1. If Claim DOS Thru 9/30/2018


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DRG Birth Weight Range in Grams 589 less than 500 591 500 thru 749 593 750 thru 999 602,603 1000 thru 1249 588 less than 1500 607,608 1250 thru 1499 611 thru 614 1500 thru 1999 609 1500 thru 2499 622,623,625,626 2000 thru 2499 630,631,634,636,639,640 greater than 2499 EDIT 349- VERIFY METRIC QUANTITY REPORTED This edit is posted for: Prof and OP (J/Q) medical injectable that have: a- The Form Code indicator on the Drug Master file is equal to 2 indicating a liquid drug. b- The route description on the Drug Master file is equal to 'INTRAVEN' or 'INJECTION' c- The STC on the Drug Master file identified by THERAP- CLASS-SP PIC X(03) is equal to one of the

following 'C1A', 'C1B', 'C1D', 'C5J', 'C5K', 'C5L', 'C5M', 'C5R', 'C1U', 'C1W'. AND - metric quantity on the claim is less than the package size of the NDC on the drug file OR - A remainder when the metric quantity on the claim is divided the package size listed for the NDC on the drug

file. OR - Has a Daily Dose (NDC Package Size listed for NDC on the drug file/claim metric quantity listed on the

claim) that exceeds the maximum units listed below for the corresponding package size.

Package Size Maximum Units 50 8 100 8 150 8 200 8 250 8 500 4 1000 4 2000 2


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EDIT 364 - CANNOT ADJ LINE LEVEL SURGERY This edit is posted if a line level surgical procedure code is adjusted on an outpatient claim when the ICD-ALLOWED-IND is equal 'N' on the approved paid claim. The ICD-ALLOWED-IND is set to 'N' for all Outpatient and Outpatient Crossover HIPAA 5010 claims and paper or Web claims with an ICN Julian Date > 2011364. If the original claim revenue code is a valid surgical revenue code and the original procedure code is a valid HCPCS surgical procedure code, edit 364 is posted if an adjustment is submitted that either changes the HCPCS surgical procedure code, or changes the revenue code to a non-surgical revenue code. Edit 364 is also posted if the original revenue and procedure code is not a valid surgical procedure code, and the adjustment revenue and procedure code is a valid surgery. Valid surgical revenue codes: 360, 361, 369, 370, 374, 379, 490, 499, 710, 719 Valid HCPCS surgical procedure codes: 10000-69999, W0000-W6999, 90870, W9027, W9029, W9030, W9031

Documents

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